SHM Converge Scientific Abstract ePoster Gallery-Cardiac Adaptations and Hemodynamic Consequences in End-Stage Carcinoid Disease

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This case report describes an elderly man with end-stage carcinoid heart disease (CaHD) who developed new hypoxia from a large right-to-left intra-atrial shunt. He had a remote history of small bowel carcinoid tumors resected about two decades earlier and had been symptom-free for years. He later presented with worsening dyspnea, increased oxygen needs, and platypnea-orthodeoxia. His medical history also included ESRD on hemodialysis and atrial fibrillation.<br /><br />Echocardiography showed progressive right-sided cardiac disease: severe tricuspid and pulmonic regurgitation, right ventricular dilation and dysfunction, elevated right atrial pressure, and preserved-to-mildly reduced left ventricular function. A bubble study in September 2024 demonstrated a very large right-to-left shunt on the first beat after agitated saline injection, consistent with an interatrial communication such as a PFO or functional atrial septal defect. The shunt likely contributed to hypoxia by allowing deoxygenated blood to bypass the lungs, especially in the setting of elevated right-sided pressures.<br /><br />The report highlights that carcinoid tumors can secrete vasoactive mediators such as serotonin, histamine, kallikrein, substance P, tachykinins, and prostaglandins, which damage right-sided valves and can lead to severe right heart failure. Left-sided involvement is uncommon unless a PFO is present. CaHD is associated with poor prognosis, and surgical valve intervention may improve short-term survival, but this patient was considered too high risk for surgery.<br /><br />The key learning points are: early cardiac evaluation is crucial in carcinoid syndrome; new hypoxia in CaHD should prompt evaluation for an intra-atrial shunt; and in advanced disease, care should prioritize symptom relief, volume optimization, and quality of life.

Asset Subtitle

Reniell X. Iñiguez

Meta Tag

Author List Ajay Bhasin, Alexander M. Hurtado, Ikeoluwapo Bolakale-Rufai, Reniell X. Iñiguez

Category Clinical Vignettes

Concept Carcinoid Heart Disease

Concept Valvular Disease

Concept Vasoactive Mediators

Concept Tricuspid Regurgitation

Concept Pulmonic Regurgitation

Distinguished Non-Finalist

Presenter Organization Northwestern McGaw Memorial Hospital

Presenting Author Reniell X. Iñiguez

Track Adult

Keywords

carcinoid heart disease

right-to-left shunt

hypoxia

platypnea-orthodeoxia

tricuspid regurgitation

pulmonic regurgitation

atrial septal defect

patent foramen ovale

right heart failure

echocardiography

Carcinoid Heart Disease

Valvular Disease

Vasoactive Mediators

Tricuspid Regurgitation

Pulmonic Regurgitation